THE UPHILL BATTLE OF HEALTH SERVICE DELIVERY IN

UNCLAS CAPE TOWN 000058


E.O. 12958: N/A
TAGS: SF SOCI
SUBJECT: THE UPHILL BATTLE OF HEALTH SERVICE DELIVERY IN
EASTERN CAPE

REF: 08 CAPE TOWN 000254


1. (SBU) Summary: The administration of South Africa's
Eastern Cape province is widely derided as the worst in the
country, and the province's inability to effectively provide
health services to its citizens epitomizes the challenges --
both self-inflicted and inherent -- faced by provincial
government. The provincial government's ability to provide
care is limited by the Eastern Cape's extreme poverty, low
rates of urbanization, and a legacy of maladministration from
the apartheid years. Although provincial leadership has made
strides expanding access to health services during the past
15 years, it has been unable to address severe capacity
shortfalls that have resulted in underspending, poor
planning, abysmal record keeping, and high vacancy rates.
Discussions in late January between Econoff and provincial
health officials and analysts suggest fixing the province's
severe management and administrative shortfalls is the first
step to improving health service delivery, but few saw much
light on the horizon that it would happen any time soon. End
summary.

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EASTERN CAPE RURAL AND POOR
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2. (U) Much ink has been spent by analysts and journalists in
the past 15 years about the problems of Eastern Cape, which
is widely viewed as the worst-governed and most
inadequately-serviced province in the country. While neither
national, provincial, nor local governments have adequately
addressed the province's needs, it is worth taking into
account the province's inherent disadvantages before properly
assessing government shortcomings. Eastern Cape is South
Africa's poorest province -- provincial statistics note that
69.6 percent ot ifs approximately 6.5 million people live in
poverty. Furthermore, just 30 percent of the province is
considered urban, a number that would be far lower without
the inclusion of the Nelson Mandela metropolitan municipality
(Port Elizabeth),the Eastern Cape's economic hub. Such low
rates of urbanization limit the province's economic potential
-- Eastern Cape has one of the country's highest unemployment
rates -- and also the government's ability to deliver
services in an effective manner. The lack of economic
opportunity has also created demographic challenges, in that
young people (men especially) have left the province in large
numbers to seek work, leaving behind the very old and very
young.


3. (SBU) The Eastern Cape province birthed after South
Africa's 1994 democratic transition also faced tremendous
administrative challenges that still have not been solved
today. The province was forced to amalgamate the
administrations of the Eastern Province of the Cape province
with the abysmally-run homelands of the Ciskei and Transkei
in the province's west. Litha Klaas, the province's Director
of Integrated Health Services, told Econoff that it took
until about 1999 before health and other departments were
somewhat effectively integrated. However, many civil
servants from the old homeland administrations -- whose jobs
were protected after 1994 -- remain on the job and are often
problematic, non-performing employees who tend to be less
qualified and motivated than those hired since. Although the
department has a human resource strategy to address their
underperformance, Klaas said that in practice it is highly
difficult to enforce.

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HEALTH PROVISION ABYSMAL 15 YEARS ON
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4. (SBU) Due to these and other factors, health service
delivery in Eastern Cape in 2009 is abysmal, and most
Qdelivery in Eastern Cape in 2009 is abysmal, and most
observers say it is not improving. The provincial health
department today operates 66 hospitals and over 700 clinics
in the province -- many of which have been built or expanded
upon since 1994 -- but the department's annual report
acknowledges only 45 percent of households have access to
hospitals and 70 percent have access to clinics. The primary
reason cited for low access was that they were too far away.
Citizens also complained about the quality of care; nearly
half thought their care was inadequate, citing long waits,
lack of medicines, and the absence of doctors as their
biggest complaints. The vacancy rate for the department as a
whole is 34 percent, while the vacancy rate for doctors,
nurses, and other specialist occupations hovers around 46
percent. Jay Kruuse of the Grahamstown-based Public Service
Accountability Monitor (PSAM) -- a watchdog NGO that closely
monitors provincial government performance -- notes that
difficult working conditions, low pay, and general
frustration all contribute to keep this number high. Klaas
said some staff go six months without pay, which drives many
of them away.



5. (SBU) Most observers attributed the bulk of the blame to
incompetence on behalf of the Department of Health.
Observers, both inside and outside, of the department cited
several key shortcomings:

-- Lack of management capacity. While Kruuse acknowledged
there are some talented people at the department in the
provincial capital of Bhisho, the depth and capacity of
management talent throughout the province is weak. Klaas
acknowledged this as well, noting that he and other senior
managers had to spend a lot of their time sorting out
management issues in clinics and hospitals because
administrators there are not up to the job. Because of this,
Klaas said he cannot spend enough time on policy development,
which is his actual responsibility.

-- Terrible record keeping. Although the Health Department
has in the past three years addressed problems with
underspending, it remains unclear where this money is going.
Kruuse questioned how a department with a 34 percent vacancy
rate can spend almost 100 percent of its personnel budget,
for example. The department has never received an
unqualified (i.e., clean) audit in its existence, and Kruuse
notes that the books are so bad that it is difficult to tell
whether incompetence or corruption are to blame. Mike
Bopasu, the former chair of the Health portfolio committee in
the provincial legislature (who recently defected from the
ruling ANC to the splinter party Congress of the People)
said the problem is that most book keeping is done by clerks
unqualified for the job, as accountants are almost impossible
to find, while Klaas said an additional problem is that most
reports are still paper-based because the province does not
have money for a proper IT infrastructure.

-- Poor planning. Kruuse and Klaas said the department does
not have the skilled staff to do sophisticated strategic
planning, putting them at a severe disadvantage when seeking
funds and preventing the department from knowing how to spend
what they have effectively. Kruuse cited the example of the
province's provision of anti-retroviral treatment. While an
independent 2006 report asserted that between 100,000 and
235,000 people in Eastern Cape would need such treatment in
2008, only 60,000 will be provided it because the province is
simply increasing its targets by 20,000 per year through

2011. Mamisa Chabula-Nxiwini, the Executive Director for
Public Health in the Nelson Mandela metro, noted that this
lack of planning has hamstrung much-needed educational
programs aimed at prevention, as the province is too often
forced to be reactive rather than proactive.

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NO QUICK OR EASY FIXES
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6. (SBU) Every interlocutor said that fixing health service
delivery in Eastern Cape is going to be an uphill battle,
though many pointed out the need to get the "systems" right
before anything else. Klaas and Kruuse noted that meaningful
standards and best practices are necessary to changing the
culture of non-delivery that permeates the province. Over
time, these systems will become ingrained and improve
performance. To do this, money needs to be spent in the
right way, with more focused on hiring effective managers,
accountants, and other administrators. This will not be
easy, however -- money is tight, and even at competitive
salaries it is hard to lure skilled staff to a province with
such a bad reputation.


7. (SBU) The province also has to retain the people it hires,
as it loses many doctors and nurses to other areas of the
country and the world. Klaas said that while higher salaries
would probably help this, he thinks the frustrations over
Qwould probably help this, he thinks the frustrations over
inefficiency and poor working conditions were a bigger
driver. Hence, implementing a comprehensive human resources
strategy that addresses staff concerns would go a long way
toward helping retention. Such fixes will not solve Eastern
Cape's problems with deep-rooted poverty or capacity
shortcomings, he noted, but they would help put the province
on the right track toward addressing them.

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COMMENT
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8. (SBU) Good project management and good administrative
skills are seriously lacking in the Eastern Cape provincial
government, as indicated by various contacts and by reftel.
The continued shortage of skilled managers, especially those
with financial management and accounting skills, in the
provincial government will make any significant progress in
health services delivery an uphill effort. The national
government may find it necessary to second a number of its
staff with the requisite skills to work with their Eastern
Cape provincial colleagues to bring them up to speed. End
Comment.


MAYBERRY